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Fighting the Coronavirus Pandemic, East Asian Responses. Taiwan: Swift, Meticulous and Digital

BLOG - 20 March 2020

An immediate response, before the first positive test on the island, a strict quarantine policy, a nationalized mask economy, and precise digital tools for a case-by-case situation awareness: these are the ingredients of Taiwan’s response to the COVID-19 crisis, for the first paper of our series "Fighting the coronavirus: East Asian responses", which explores the toolbox of public policy options to contain and defeat the virus.

Key policies

  • Responses 21 days BEFORE a first case is detected: as early as December 31 with increased inspection measures to screen passengers on inbound travel from Wuhan for early signs, with a Central Epidemic Command Center activated by January 20, under the centralized authority of Minister of Health and Welfare.
  • Delay between first case and most strong measures in place: 2 to 11 days.
  • Integration on January 27 of databases to ensure access to the travel history of suspected cases to the National Health Administration
  • Extremely strict enforcement of quarantine rules: intrusive tracing during the 14-day incubation period, screening of contact history, fines for violators, allowing Taiwan to avoid confinement and major lockdowns
  • Testing of individuals showing symptoms but no systematic testing of individuals quarantined
  • Strong focus from Jan. 24 on surgical and N95 mask production and distribution: government measures to ramp up production, rationing and nationalization of distribution, early export ban, and a nation-wide digital system to show the availability of masks in real-time
  • Entry bans gradually expanding from Hubei residents to all Chinese nationals in early February and to all foreigners in mid-March (with an exception for low-skill foreign labor)
  • A rule-of-law approach based on the standard operations procedures detailed in the Communicable Diseases Control Act 

Timeline

  • December 31: 2019: Taiwanese officials start assessing inbound passengers flying from Wuhan for fever and pneumonia-like symptoms on the planes upon landing
  • January 5: Individuals who have traveled to Wuhan in the past 14 days start being screened for symptoms
  • January 20: Activation of the Central Epidemic Command Center for coordinating and implementing crisis management
  • January 21: First case detected in Taiwan, a Wuhan-based Taiwanese businesswoman returning home
  • January 22: The Executive Yuan announces fines for disseminating epidemic fake news content, up to NT$ 3 million (US$ 100000)
  • January 24: One-month export ban on surgical masks
  • January 28: First case of Taiwanese national infected in Taiwan
  • January 29: Adoption of electronic monitoring of quarantined individuals
  • January 30: Fixation of a price for surgical masks (NT$8)
  • February 1: The Executive Yuan passes a special budget of NT$200 million (US$6.6 million) to help manufacturers increase mask production capacity
  • February 6: Entry ban on Chinese nationals
  • February 7: Entry ban on foreign nationals who have traveled to China, Hong Kong and Macao in the past 14 days
  • February 16: Extension of the National Health Administration Database to cover 30-day travel history
  • February 26: President Tsai Ing-wen promulgates the Special Act on Covid-19 Prevention, Relief and Restoration providing for a NT$60 billion (US$1.97 billion) special budget to help businesses, workers and the health sector, and reviewing fines and penalties for breaking quarantine or hoarding medical supplies
  • March 10: President Tsai Ying-wen promulgates the Regulations Governing the Compensation for Periods of Isolation and Quarantine for Severe Pneumonia with Novel Pathogens
  • March 18: 23 new cases confirmed, the single highest increase since the beginning of the outbreak, with 22 returning from Europe, Asia or the US.
  • March 18: Entry ban on foreign nationals and 14-day quarantine for all inbound Taiwanese travelers 

Analysis

Taiwan is widely heralded as a successful containment model of Covid-19 outbreak. As of March 18, two months after the first positive test was registered in Taiwan, and despite the deep human and economic integration of the island with Mainland China, only 100 individuals had tested positive to the virus, with one death on February 16.
 
This result has been achieved on the basis of an immediate recognition, by the end of December 2019, of the gravity of the crisis. Like many East Asian states, Taiwan learned lessons during the traumatizing 2003 SARS crisis. Taiwan’s current Vice-President Chen Chien-jen, who was Director General of the Department of Health during the SARS crisis, said in an interview that his first reaction to the detection of severe pneumonia cases in Wuhan was “Wow! SARS has returned”. He then realized that the coronavirus was both much more transmissible and harder to detect given the long incubation period and the mild symptoms shown by a majority of cases.

This result has been achieved on the basis of an immediate recognition, by the end of December 2019, of the gravity of the crisis.

The lessons of SARS were put into practice. The Center for Disease Control under the Ministry of Health started fever screening for arriving passengers and full-scale examinations for suspected cases on all flights from Wuhan as early as December 31. With contagion spreading in Hubei province and in China, the government activated in January 2020 the Central Epidemic Command Center (CECC) for Severe Special Infectious Pneumonia, allowing mobilization of national resources to prevent an outbreak in the island.

Taiwan’s policy response to the coronavirus pandemic has taken advantage of digital technologies and big data to allow for precise live monitoring of the situation and make information available to health sector professionals and the general population.
 
Integrating data from the National Health Administration and Customs was one of the first moves of the Taiwanese government to strictly monitor the risk of imported Covid-19 cases. This allowed the health administration to access the 14-day travel history of any individual, and later their 30-day travel history. Taiwan’s Executive Yuan allowed all hospitals, clinics and pharmacies to access the patients’ travel history. To enhance the monitoring of incoming travelers to the island, the Taiwanese government created a mandatory health declaration for all inbound passengers. Providing inaccurate information can lead to a fine up to US$ 5000. This declaration provided a basis for classifying travelers into risk categories and implement Taiwan’s quarantine policy. 
 
The stored data of the National Health Administration was also used to identify 113 individuals who had consulted for severe respiratory syndromes in January and February and tested negative for influenza. They were all proactively re-tested for Covid-19, and one tested positive. This sophistication in the use of medical data and digital tools relies on wide data collection practices. All health professionals on the frontline have been trained to ask patients about their travel history, occupation, contact history and “cluster” – the group activities in which they have recently been involved – when consultations reveal respiratory syndromes.
 

Taiwan’s crisis management is characterized by a strong emphasis on the necessity of wearing masks. Taiwan has essentially created a nationalized mask economy. The government organizes production, imposes rationing, centralizes distribution and has acted to preempt panic-buying by focusing on the combat against fake news.

1 800 reserve troops to join the production lines.

On the production side, Taiwan enacted a temporary export ban on surgical and N95 masks; and ordered on February 11 the installation of 60 production lines to boost mask production from 4 million to 10 million units per day. The military mobilized 1 800 reserve troops to join the production lines. Many media reports praise the companies for 24 hours no-interruption production – in Tainan city, the company Ge’ande increased its daily production from 200 000 to 600 000 units per day by adding 39 workers from the military to its staff of 10 employees.
 
Taiwan started implementing a rationing system in early February, making masks only available at pharmacies, medical stores and in the ubiquitous network of convenience stores. In practice, the distribution system is linked to National Health Insurance cards. Each citizen is allowed to buy three masks on designated days based on the last digit of their social security number. Their purchase history is stored in the system for each selling unit to check. To ensure the effective allocation of masks to selling points, the national distribution of masks is carried out through the mobilization of the state-owned Chunghwa post company. 1,4 million masks have been allocated each day to the medical workforce in the early stages of the outbreak. This distribution system was complemented by a government-managed ordering website that went online on March 12.
 
Taiwan’s national mask economy is digitalized so that the population has full visibility of the availability of masks. An application integrating Google Maps shows on each connected device the stocks of masks in all designated selling locations. Access to that information is also possible through Line (the main chat app in Japan and Taiwan) and other applications. This effort required the setting up of 20 servers by the National Health Insurance Administration (making it 32 in total) to ensure the cloud capacity to handle the surplus traffic.

 

Strict quarantine of risky individuals, rather than confinement or testing, is the cornerstone of Taiwan’s crisis management.

Taiwan’s policy is intrusive when it comes to monitoring quarantined individuals. Once an individual is placed in quarantine, on the basis of their health declaration upon arrival in Taiwan or on the basis of their contact history, they have to follow strict rules. The Taiwanese government provides quarantined individuals with a mobile phone to monitor their whereabouts during their quarantine period. Upon request, health authorities can be given access to police and mobile phone records to track with whom infected or risky persons have been in contact and extend quarantine measures. Digitalization is thus an essential tool to enforce Taiwan’s strict quarantine. 

But the threat of sanctions also matters enormously. In the space of two weeks in early March, Taipei municipal government sanctioned 70 individuals for violating quarantine regulations, with dissuasive fines up to 1 million NT$ (29 871€). And the “Special Act on Covid-19 Prevention, Relief and Restoration” (嚴重特殊傳染性肺炎防治及紓困振興特別條例) allows the government to film and photograph people who break quarantine and publish their personal information – a naming and shaming approach. However, sanctions is not the only aspect of the quarantine policy. The Taiwanese government has promulgated legislation to compensate quarantined individuals when they have to take care of children under 12 – the compensation is of NT$1,000 (US$33.35) per day.

In sum, strict quarantine of risky individuals, rather than confinement or testing, is the cornerstone of Taiwan’s crisis management. This has allowed the Taiwanese government to focus testing on individuals showing Covid-19 symptoms. Backed by precise data access and prohibitive sanctions, complemented by travel bans and proactive screening, the strict approach to quarantine has so far allowed Taiwan to contain the contagion. 

Taiwanese hospitals have thus been able to anticipate and focus on best managing patient flows, in order to guarantee the isolation of Covid-19 infected patients in the event of a sudden case increase. The country has a limited number of beds in isolation negative pressure wards (943) but government officials have announced that the reconfiguration of wards and use of single-bed rooms was possible to build isolation capacity if necessary. The Executive Branch has also adopted a special budget to address the cost of crisis management, including the longer term cost on economic activity, when enacting Special Act on Covid-19 Prevention, Relief and Restoration (嚴重特殊傳染性肺炎防治及紓困振興特別條例), which includes a stimulus package of maximum NT$60 billion (US$1.97 billion).

All in all, despite a population of 23,78 million, Taiwan has managed to focus on individual cases and their entourage and to craft a policy response based on precise situation awareness to preempt contagion, relying on digital technologies to monitor, inform and impose sanctions against socially dangerous behavior.

 

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